3 Diagnostic Criteria
Although not all addictions counselors will provide formal diagnoses of clients, it is imperative that they understand the criteria used to develop a diagnosis of Substance Use Disorder (SUD). Addiction is a relatively new field, and our understanding and research of this problem are still in their infancy. As we better grasp the nature of addiction, definitions can be updated to reflect that new knowledge.
The American Psychiatric Association has been the center of the diagnostic world in the United States since the release of the first Diagnostic and Statistical Manual (DSM) in 1952. The first mention of addiction appeared in the original DSM and was used to describe someone with a Sociopathic Personality Disturbance[1]
In 1980, DSM-III incorporated Substance Dependence and Substance Abuse as two distinct categories of problematic substance use. These categories remained until 2013 when DSM-5 combined them into one category called Substance Use Disorder with 11 defining criteria that encompass physical dependence, risky use, and social problems associated with using.
Future paradigms around diagnosis and treatment will reflect both the current body of knowledge and the advances that are yet to come. Counselors in the addiction field will need to be aware of the historical foundations of diagnosis, current ways of describing addiction, and ongoing developments that will continue to shape treatment.
The following video highlights key terminology from the DSM related to Substance Use Disorder.
case study
Exercise: Case Study of Marie
Background
Marie is a 57 year-old Latina woman who has been married for 30 years. She and her partner have two adult children, aged 26 and 28, and three grandchildren. Marie taught elementary school for 32 years and has not worked since retiring two years ago.
She sees her family doctor for control of asthma and high blood pressure and takes medication for both. The same family doctor has treated the client for nearly 20 years.
Her mother suffered with hypertension and died of a stroke 10 years ago at age 77. Her father died after a heart attack more than 20 years ago at age 62. She has two younger sisters who are in good health.
For much of the time she has known Marie, the family doctor has been aware of the client’s problems with alcohol. Marie reports that her drinking began in the early 1990s after she was involved in a lawsuit initiated by a parent of one of her students. Although the school supported her, and the case was eventually resolved in her favor, she remembers that time as one of constant fear and uncertainty.
She recalls subsequently experiencing blackout spells when she drank. On three separate occasions, she was hospitalized for detoxification, and brief periods of sobriety ensued. Her doctor inquires regularly about her alcohol use and believes that Marie is truthful about her bouts of drinking and times of abstinence.
One week ago, Marie’s husband and one of her daughters called the doctor to express their concern about her. The husband related that his wife had resumed daily drinking of vodka three months ago. At times, he noticed that she slurred her words. Her daughter has become fearful of leaving the grandchildren with Marie. When her family each spoke with her, Marie denied drinking too much and thought they made “more of the problem than there was.”
The doctor contacted Marie and told her that her husband and daughter had spoken with him, and she agreed to come in for an appointment. The doctor pointed out that the problem was not new, that it was causing marital and family consequences for her, that she had made several unsuccessful attempts to deal with it in the past, and that she felt it was time to take a definitive step to resolve the problem. After seeing the doctor, Marie agreed to accept a referral to a treatment center for an assessment and any follow-up recommendations.
Counseling Assessment
Marie presents to Bluebird Counseling for an evaluation. She is quiet but cooperative during her interview. She also signed a release of information so that your agency can communicate with her doctor about treatment.
She acknowledges that her drinking has become more intense lately and that it might be affecting her relationship with her family. When asked about her family’s concerns, Marie acknowledged them but reiterated that she thinks they are overstating how much she drinks.
She states that her last drink was yesterday evening, about 12 hours ago, and that she had “maybe 4-5 mixed drinks with vodka.” She reports that she occasionally feels shaky in the morning when she wakes up and will take a drink to “steady myself for the day.”
She says that she drinks most days of the week, usually between 3-5 drinks but sometimes less and sometimes more. Her primary drink is vodka mixed with some kind of juice. She has noticed that the number of drinks she needs to “feel better” has gone up recently.
She denies use of any other types of alcohol and denies any other current drug use.
Client says she previously used cannabis in the form of joints, smoking once or twice a month when she was in her 20s, but denies using “since my children were born.”
Marie’s doctor noted that her medical tests indicated elevated liver enzymes, a possible indication of liver functioning problems.
Marie says she is willing to participate in a treatment program, although she is hopeful it will not be “somewhere I have to stay.”
Marie denies driving her car when she drinks, and she has a valid license and access to a car.
Marie says she has never been in a formal treatment setting, aside from detoxification, although she has attended Alcoholics Anonymous meetings on two occasions, saying “I didn’t feel like I fit in there.”
Marie reports that her Catholic faith is important to her, although she does not attend church as often as she used to.
DSM-5 Criteria for Substance Use Disorder
Note: Current diagnosis relates to behavior within the past 12 months
The phrase ‘As evidenced by’ is a way of documenting the specific behavioral examples that fulfill the category or criterion. For example, a client might report that they have had a prior treatment episode or had made efforts to reduce or quit their use. These experiences would meet the criterion for unsuccessful efforts to quit or cut down on use.
The table below provides a way for counselors in training to practice identifying criteria presented by a client’s assessment using the exact language of the DSM and linking a certain criterion to observed or reported client behavior.
| Check if Applies | DSM Criterion | As Evidenced By |
| The drug is often taken in larger amounts or over a longer period of time than intended. | ||
| There is a persistent desire or unsuccessful efforts to cut down or control drug use. | ||
| A great deal of time is spent in activities necessary to obtain the drug, use the drug, or recover from its effects. | ||
| Craving, or a strong desire to use the drug. | ||
| Recurrent use resulting in failure to fulfill major role obligations at work, school, or home. | ||
| Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the drug. | ||
| Important social, occupational, or recreational activities are given up or reduced because of use. | ||
| Recurrent use in situations in which it is physically hazardous. | ||
| Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by using. | ||
| *Tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of the drug to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the drug |
||
| *Withdrawal, as manifested by either of the following:
(a) the characteristic withdrawal syndrome for the drug (b) the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms |
*Tolerance and withdrawal criteria are not considered to be met if the individual is taking opioids solely under appropriate medical supervision.
Severity can be evaluated as follows: Mild: 2-3 symptoms. Moderate: 4-5 symptoms. Severe: 6 or more symptoms
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, D C. American Psychiatric Association.
Exercise: Applying DSM Criteria
Based on DSM criteria, what is your diagnostic impression of Marie?
- Provide a diagnostic impression
- List supporting criteria from the DSM
Exercise: Clinical Evaluation
Identify relevant issues for Marie in each of the six ASAM criteria.
Dimension 1: Acute Intoxication & Withdrawal Potential
(Exploring past and current experiences of substance use and withdrawal)
Dimension 2: Biomedical Conditions and Complications
(Health history and current physical condition)
Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications
(Thoughts, emotions, and mental health issues)
Dimension 4: Readiness to Change
(Readiness and interest in changing; stage of change)
Dimension 5: Relapse, Continued Use, or Continued Problem Potential
(What are the issues or barriers related to risk of relapsing or continuing use?)
Dimension 6: Recovery/Living Environment
(Recovery or living situation & surrounding people, places, and things)
Exercise: Treatment Referral
Level 1 = Outpatient
Level 2.1 = Intensive Outpatient
Level 2.5 = Partial Hospitalization
Level 3.1 = Low-intensity residential (halfway house)
Level 3.5 = High-intensity residential
Level 4 = Medically managed inpatient
Rationale:
Exercise: Initial Treatment Plan / Master Problem-Goal List
- Michael A. Norko and W. Lawrence Fitch Journal of the American Academy of Psychiatry and the Law Online December 2014, 42 (4) 443-452. ↵
